| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0220 |
Intraoral - periapical first radiographic image |
388 |
374 |
$117.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
178 |
177 |
$114.00 |
| D0140 |
Limited oral evaluation - problem focused |
126 |
123 |
$105.00 |
| D0210 |
Intraoral - complete series of radiographic images |
25 |
25 |
$58.00 |
| D1206 |
Topical application of fluoride varnish |
321 |
316 |
$57.00 |
| D1110 |
Prophylaxis - adult |
42 |
42 |
$47.00 |
| D0274 |
Bitewings - four radiographic images |
44 |
43 |
$29.00 |
| D0120 |
Periodic oral evaluation - established patient |
48 |
48 |
$28.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
227 |
198 |
$27.00 |
| D4921 |
|
71 |
41 |
$0.00 |
| D0602 |
|
12 |
12 |
$0.00 |